Introduction: Freestanding Emergency Departments (FEDs) have grown in number and understanding their impact on the healthcare system is important. Sepsis causes significant morbidity and mortality and identifying how FEDs impact sepsis morbidity and mortality has not been studied. The objective of this study was to determine if there is a difference in in-hospital mortality for sepsis patients who present initially to FEDs compared to a hospital-based ED. Methods: This was a retrospective cohort of adult patients seen at a hospital-based ED or one of three FEDs within a large hospital system from 1/1/2018-10/31/2020. We included those who were diagnosed with sepsis, severe sepsis or septic shock and evaluated ED throughput measures, in-hospital mortality, and hospital length of stay. Categorical variables are presented as frequencies and percentages. Continuous variables are presented as mean and standard deviations or median and quartiles depending on distribution. Multiple logistic regression was fit to compare in-hospital mortality rates between the two groups. Variables controlled for included Charlson Comorbidity Index, race, gender, insurance, and sepsis severity. Wilcoxon rank sum tests were used to compare the time metrics. Results: There were 1955 patients included in the study. Mean age of participants was 61.9 at the FEDs vs 63.7 at the HBED. Majority of the participants were white; 88.2% at the FED vs. 77.3% at the HBED; and male 49.0% at the FED vs. 51.1% at the HBED. Most patients had Medicare; 45.4% at the FED vs. 58.3% at the HBED. In-patient mortality rate was significantly lower for patients that presented to FEDs compared to HBED (95%CI 0.13-0.46) adjusted odds ratio 0.24. Time to IV fluids, time to lactate, time to blood cultures, time to ED disposition, ED LOS, time to arrival on the inpatient unit were all significantly lower for FEDs vs HBED (p < 0.05). Conclusion: Patients presenting to FEDs for sepsis, severe sepsis and septic shock had lower inpatient mortality, quicker treatment times, and were transferred and admitted to the hospital faster than patients seen at a HBED. Weniger anzeigen

Background: Nighttime hospital admission is often associated with increased mortality risk in various diseases. This study investigated compliance rates with the Surviving Sepsis Campaign (SSC) 3-h bundle for daytime and nighttime emergency department (ED) admissions and the clinical impact of compliance on mortality in patients with septic shock. Methods: We conducted an observational study using data from a prospective, multicenter registry for septic shock provided by the Korean Shock Society from 11 institutions from November 2015 to December 2017. The outcome was the compliance rate with the SSC 3-h bundle according to the time of arrival in the ED. Results: A total of 2049 patients were enrolled. Compared with daytime admission, nighttime admission was associated with higher compliance with the administration of antibiotics within 3 h (adjusted odds ratio (adjOR), 1.326; 95% confidence interval (95% CI), 1.088-1.617, p = 0.005) and with the complete SSC bundle (adjOR, 1.368; 95% CI, 1.115-1.678; p = 0.003), likely to result from the increased volume of all patients and sepsis patients admitted during daytime hours. The hazard ratios of the completion of SSC bundle for 28-day mortality and in-hospital mortality were 0.750 (95% CI 0.590-0.952, p = 0.018) and 0.714 (95% CI 0.564-0.904, p = 0.005), respectively. Conclusion: Septic shock patients admitted to the ED during the daytime exhibited lower sepsis bundle compliance than those admitted at night. Both the higher number of admitted patients and the higher patients to medical staff ratio during daytime may be factors that are responsible for lowering the compliance. Weniger anzeigen

Objectives: To test the hypothesis that forced-air warming of critically ill afebrile sepsis patients improves immune function compared to standard temperature management. Design: Single-center, prospective, open-label, randomized controlled trial. Setting: One thousand two hundred-bed academic medical center. Patients: Eligible patients were mechanically ventilated septic adults with: 1) a diagnosis of sepsis within 48 hours of enrollment; 2) anticipated need for mechanical ventilation of greater than 48 hours; and 3) a maximum temperature less than 38.3°C within the 24 hours prior to enrollment. Primary exclusion criteria included: immunologic diseases, immune-suppressing medications, and any existing condition sensitive to therapeutic hyperthermia (e.g., brain injury). The primary outcome was monocyte human leukocyte antigen (HLA)-DR expression, with secondary outcomes of CD3/CD28-induced interferon gamma (IFN-γ) production, mortality, and 28-day hospital-free days. Interventions: External warming using a forced-air warming blanket for 48 hours, with a goal temperature 1.5°C above the lowest temperature documented in the previous 24 hours. Measurements and main results: We enrolled 56 participants in the study. No differences were observed between the groups in HLA-DR expression (692 vs 2,002; p = 0.396) or IFN-γ production (31 vs 69; p = 0.678). Participants allocated to external warming had lower 28-day mortality (18% vs 43%; absolute risk reduction, 25%; 95% CI, 2-48%) and more 28-day hospital-free days (difference, 2.6 d; 95% CI, 0-11.6). Conclusions: Participants randomized to external forced-air warming did not have a difference in HLA-DR expression or IFN-γ production. In this pilot study, however, 28-day mortality was lower in the intervention group. Future research should seek to better elucidate the impact of temperature modulation on immune and nonimmune organ failure pathways in sepsis. Weniger anzeigen

The world continues to contend with successive waves of coronavirus disease 2019 (COVID-19), fueled by the emergence of viral variants. At the same time, persistent, prolonged and often debilitating sequelae are increasingly recognized in convalescent individuals, named ‚post-COVID-19 syndrome‘ or ‚long-haul COVID‘. Clinical symptomatology includes fatigue, malaise, dyspnea, defects in memory and concentration and a variety of neuropsychiatric syndromes as the major manifestations, and several organ systems can be involved. The underlying pathophysiological mechanisms are poorly understood at present. This Review details organ-specific sequelae of post-COVID-19 syndromes and examines the underlying pathophysiological mechanisms available so far, elaborating on persistent inflammation, induced autoimmunity and putative viral reservoirs. Finally, we propose diagnostic strategies to better understand this heterogeneous disorder that continues to afflict millions of people worldwide. Weniger anzeigen

We present our data collected from May 11, 2020 to September 24, 2021 at the “Luigi Sacco” University Hospital, Milan, where the ARCOVID (Ambulatorio Rivalutazione COVID) outpatients’ clinic began to follow “long haulers”, periodically controlling the persistence of physical and psychological symptoms, in order to assess their duration and the predictive factors associated with their resolution. Patients aged >18 years with confirmed COVID-19 (by PCR/antibody detection) were either referred by the physicians who had taken care of them in the acute phase or came voluntarily. After signing written informed consent they were enrolled in the AntiCROWN longitudinal study of anti-S1/S2 IgG response and clinical follow-up, approved by the “Comitato Etico Interaziendale Area 1″, n. 2020/ST/158. Throughout the first visit patients received a standardized clinical examination, serological sample to detect anti-S1/S2 IgG levels, 6-minute-walk test in case of dyspnea, and, if necessary, blood work and then sometimes were referred to other specialists. Moreover, they were asked about ongoing symptoms. The follow-up continued using questionnaires sent to each patient every 3 months. Weniger anzeigen

Most children have a mild course of acute COVID-19. Only few mainly non-controlled studies with small sample size have evaluated long-term recovery from SARS-CoV-2 infection in children. The aim of this study was to evaluate symptoms and duration of ‚long COVID‘ in children. A nationwide cohort study of 37,522 children aged 0-17 years with RT-PCR verified SARS-CoV-2 infection (response rate 44.9%) and a control group of 78,037 children (response rate 21.3%). An electronic questionnaire was sent to all children from March 24th until May 9th, 2021. Symptoms lasting > 4 weeks were common among both SARS-CoV-2 children and controls. However, SARS-CoV-2 children aged 6-17 years reported symptoms more frequently than the control group (percent difference 0.8%). The most reported symptoms among pre-school children were fatigue Risk Difference (RD) 0.05 (CI 0.04-0.06), loss of smell RD 0.01 (CI 0.01-0.01), loss of taste RD 0.01 (CI 0.01-0.02) and muscle weakness RD 0.01 (CI 0.00-0.01). Among school children the most significant symptoms were loss of smell RD 0.12 (CI 0.12-0.13), loss of taste RD 0.10 (CI 0.09-0.10), fatigue RD 0.05 (CI 0.05-0.06), respiratory problems RD 0.03 (CI 0.03-0.04), dizziness RD 0.02 (CI 0.02-0.03), muscle weakness RD 0.02 (CI 0.01-0.02) and chest pain RD 0.01 (CI 0.01-0.01). Children in the control group experienced significantly more concentration difficulties, headache, muscle and joint pain, cough, nausea, diarrhea and fever than SARS-CoV-2 infected. In most children ‚long COVID‘ symptoms resolved within 1-5 months.Conclusions: Long COVID in children is rare and mainly of short duration. What is Known: • There are increasing reports on ‚long COVID‘ in adults. • Only few studies have evaluated the long-term recovery from COVID-19 in children, and common for all studies is a small sample size (median number of children included 330), and most lack a control group. What is New: • 0.8% of SARS-CoV-2 positive children reported symptoms lasting >4 weeks (‚long COVID‘), when compared to a control group. • The most common ‚long COVID‘ symptoms were fatigue, loss of smell and loss of taste, dizziness, muscle weakness, chest pain and respiratory problems. • These ‚long COVID‘ symptoms cannot be assigned to psychological sequelae of social restrictions. • Symptoms such as concentration difficulties, headache, muscle- and joint pain as well as nausea are not ‚long COVID‘ symptoms. • In most cases ‚long COVID‘ symptoms resolve within 1-5 months. Weniger anzeigen

Background: Previous randomized trials of vitamin C, hydrocortisone, and thiamine on sepsis were limited by short-term vitamin C administration, heterogeneous populations, and the failure to evaluate each component’s effect. The purpose of this study was to determine whether vitamin C alone for ≥ 5 days or in combination with corticosteroids and/or thiamine was associated with decreased mortality across the sepsis population and subpopulation. Methods: Nationwide population-based study conducted using the Korean National Health Insurance Service database. A total of 384,282 adult patients with sepsis who were admitted to the intensive care unit were enrolled from January 2017 to December 2019. The primary outcome was hospital mortality, while the key secondary outcome was 90-day mortality. Results: The mean [standard deviation] age was 69.0 [15.4] years; 57% were male; and 36,327 (9%) and 347,955 did and did not receive vitamin C, respectively. After propensity score matching, each group involved 36,327 patients. The hospital mortality was lower by – 0.9% in the treatment group (17.1% vs 18.0%; 95% confidence interval, – 1.3 to – 0.5%; p < 0.001), a significant but extremely small difference. However, mortality decreased greater in patients who received vitamin C for ≥ 5 days (vs 1-2 or 3-4 days) (15.8% vs 18.8% vs 18.3%; p < 0.001). Further, vitamin C was associated with a lower hospital mortality in patients with older age, multiple comorbidities, pneumonia, genitourinary infection, septic shock, and mechanical ventilation. Consistent findings were found for 90-day mortality. Moreover, vitamin C alone or in combination with thiamine was significantly associated with decreased hospital mortality. Conclusions: Intravenous vitamin C of ≥ 5 days was significantly associated with decreased hospital and 90-day mortality in sepsis patients. Vitamin C combined with corticosteroids and/or thiamine in specific sepsis subgroups warrants further study. Weniger anzeigen

Introduction: Concern for loss of physical performance and Health-Related Quality of Life (HRQoL) may raise doubts regarding the meaningfulness of an Intensive Care (ICU) admission in elderly patients. We evaluated self-perceived long-term recovery and satisfaction in elderly surviving an abdominal sepsis related ICU-admission and related this to objective measures of HRQoL. Methods: A cross-sectional survey study was performed in all ICU-survivors with age ≥70 admitted with abdominal sepsis. HRQoL, frailty and self-perceived long-term recovery were measured using the EQ-5D-3L, Groningen Frailty Indicator, and a self-developed questionnaire, respectively. Results: Of 144 patients admitted, 48 were alive at follow up (2.42 [0.92; 3.83] years), and 29 (60%) returned the survey. Eleven patients out of 29 (38%) recovered to baseline functioning, and reported higher HRQoL compared to unrecovered patients (0.861 [0.807; 1.000] and 0.753 [0.499; 0.779] respectively, p=0.005). Of the unrecovered patients, 53% were satisfied with their functioning, and 94% were willing to return to ICU. Conclusions: Mortality in elderly patients with abdominal sepsis is high and ICU-admission should be weighed carefully. However, despite substantial functional decline in survivors, it does not necessarily cause self-perceived unsatisfactory functioning, poor HRQoL and unwillingness to receive life-sustaining therapy again. Caution is advised to use an anticipated loss of functioning as an argument to deny an ICU-admission. Weniger anzeigen

Background: Sepsis is a leading cause of mortality in patients with neutropenia; however, data on whether neutropenic sepsis is associated with distinct clinical characteristics and outcomes are limited. Thus, this study was designed to clarify the clinical characteristics and outcomes of patients with neutropenic sepsis compared with those of patients without neutropenic sepsis diagnosed based on the Third International Consensus Definitions for Sepsis and Septic Shock criteria. Methods: We analyzed data from the Korean Sepsis Alliance, a nationwide prospective multicenter cohort study evaluating the clinical characteristics, management, and outcomes of patients with sepsis from September 2019 to February 2020. Eligible patients were divided into the neutropenic (absolute neutrophil count of less than 1,500/mL) and non-neutropenic groups. The characteristics and outcomes were compared between the two groups. Results: During the study period, 2,074 patients were enrolled from 16 tertiary referral or university-affiliated hospitals. Of them, 218 (10.5%) had neutropenia. The neutropenia group was younger and had a lower proportion of patients with chronic diseases compared to the non-neutropenia group. However, solid tumors (50.0% vs. 34.1%; P > 0.001) and hematological malignancies (40.8% vs. 3.8%; P < 0.001) were more common in the neutropenia group. The neutropenia group had a higher incidence of septic shock (43.6% vs. 22.9%; P < 0.001) and higher Sequential Organ Failure Assessment score (7 vs. 5; P < 0.001) than the non-neutropenia group. However, no significant differences in microbiologically confirmed infections and its pathogen distribution and the incidence of multidrug resistance were observed between the two groups. The neutropenic group had a higher hospital mortality than the non-neutropenic group (42.2% vs. 26.3%; P < 0.001), and the Kaplan-Meier survival curve demonstrated a significant difference in survival within 1 week after diagnosing sepsis (log-rank test, P = 0.002). The incidence of adverse events during intensive care unit admission was not different between the two groups. Among hospital survivors, the neutropenic group was more frequently discharged to home (72.2% vs. 57.8%; P = 0.002). Conclusions: Neutropenic sepsis is associated with a higher-grade organ dysfunction during the diagnosis of sepsis and higher mortality without difference in the pathogen isolated. Weniger anzeigen

Objectives: The rapid response team (RRT) assists hospitalized patients with sudden clinical deterioration. There is scarce evidence of diagnostic accuracy in this scenario, but it is possible that a considerable rate of misdiagnosis exists. Autopsy remains a valuable tool for assessing such question. This study aimed to compare clinical (premortem) and autopsy (postmortem) diagnoses in patients assisted by the RRT and describe major discrepancies. Methods: We reviewed 104 clinical data and autopsies from patients assisted by the RRT during a cardiac arrest event in a tertiary care hospital in Brazil. Clinical and autopsy diagnostic discrepancies were classified using the Goldman criteria. Other clinical and pathological data were described, and the group with major diagnostic discrepancies was further analyzed. Results: We found 39 (37.5%) patients with major diagnostic discrepancies. Most frequent immediate causes of death in this group determined by autopsy were sepsis (36%), pulmonary embolism (23%) and hemorrhagic shock (21%). Pulmonary embolism was the cause of death significantly more frequent in the major discrepancy group than in the minor discrepancy group (23% versus 3%, P = 0.002). We individually described all major diagnostic discrepancies. Conclusions: We found a high rate (37.5%) of major misdiagnosis in autopsies from patients assisted by the RRT in a tertiary teaching hospital. Pulmonary embolism was the most inaccurate fatal diagnosis detected by autopsy. Weniger anzeigen